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American Journal of Nursing Science
2016; 5(2): 37-44
Published online March 2, 2016 (http://www.sciencepublishinggroup.com/j/ajns)
doi: 10.11648/j.ajns.20160502.11
ISSN: 2328-5745 (Print); ISSN: 2328-5753 (Online)
The Effect of Aromatherapy Massage Using Lavender Oil
on the Level of Pain and Anxiety During Labour Among
Primigravida Women
Sahar Mansour Lamadah
1
, Ibtesam Nomani
2
1
Obstetric and Gynaecological Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt
2
Obstetric and Gynaecological Medicine, Umm Al Qura University, Makkah Al- Mukarramah, KSA
Email address:
dr.saharlamadah@yahoo.com (S. M. Lamadah)
To cite this article:
Sahar Mansour Lamadah, Ibtesam Nomani. The Effect of Aromatherapy Massage Using Lavender Oil on the Level of Pain and Anxiety
During Labour Among Primigravida Women. American Journal of Nursing Science. Vol. 5, No. 2, 2016, pp. 37-44.
doi: 10.11648/j.ajns.20160502.11
Abstract:
Background: Labour pain is considered as one of the most intense forms of pain. Psychological challenge such as
anxiety can contribute towards women’s perception of pain and may also affect their labor and birth experience. There are
modern many non-invasive methods to relieve pain during childbirth. Among these methods is aromatherapy which is the most
popular complementary therapy during child birth. Therefore this study aimed to assess the effect of aromatherapy massage
using lavender oil on the level of pain and anxiety during labor among primigravida women. Setting: the study was conducted
in the labour department at El-Shatby Maternity University Hospital in Alexandria, Egypt. A purposive sample of 60 pregnant
women participated in the study. There were randomly assigned to two groups: The first group (n= 30) received aromatherapy
back massage with 2 drops of lavender oil dissolved in 50cc almond oil and the second group (n = 30) received only back
massage. Four tools were used to collect the necessary data: An Interviewing Assessment Sheet, Partograph, Visual analogue
pain intensity scale (VAS) and Spielberger state-trait anxiety questionnaire. Results of the current study illustrated that the
mean pain score before intervention was (7.0) for aromatherapy group and (8.1) for control group. Then after intervention, the
mean pain score decreased to 6.4 during active phase for aromatherapy group compared to 8.9 for control group. Also, the
mean pain score decreased to 7.7 during transitional phase for aromatherapy group compared to 9.6 for control group. There is
a statistical significant difference between the two groups after the intervention. Moreover, the mean anxiety score before
intervention was (55.47 and 50.40) respectively among the aromatherapy and control group. However, it decreased during the
active and transitional phase to (38.40, 36.63) respectively among aromatherapy group compared to (45.13, 44.07) respectively
among control group. The difference was statistically significant. The present study concluded that aromatherapy massage with
lavender oil can reduce pain and anxiety during labour. Also, it is an effective way to decrease labor duration. It was
recommended that lavender aromatherapy massage can be offered to women in labour for pain relief.
Keywords:
Aromatherapy Massage, Lavender Oil, Labour Pain, Anxiety
1. Introduction
Child birth is a painful and stressful event in a woman's
life. Pregnant women commonly worry about pain during
labour and birth. [1] Labour pain is caused by uterine
contractions, cervical dilatation, vaginal and pelvic floor
stretching. It has been described as one of the most intense
forms of pain. [2, 3] During labour, conflicting emotions are
present; fear and unease that can be coupled with anticipation
and gladness. Anxiety and fear are factors contributing
towards women’s perception of pain and may also affect their
labour and birth experience. [4] The fear of pain during
childbirth is one of the major reasons that make women
prefer Caesarean section. In a study result reported in Iran,
37.2% of women opted for caesarean section due to anxiety
and fear of the labour pain [5].
Also, if the labour pain is not under control, mothers can
face certain risks like feeling of fear, anxiety, helplessness,
and loss of control throughout the birthing process [6].
Labour pain and loss of control are the two most frequently
cited unpleasant experiences of childbirth that may directly
affect woman’s satisfaction about childbirth. [7]
38 Sahar Mansour Lamadah and Ibtesam Nomani: The Effect of Aromatherapy Massage Using Lavender Oil on the Level of
Pain and Anxiety During Labour Among Primigravida Women
In addition, anxiety is the most common psychological
response of women to labor. In fact, 80% of women in labor
have anxiety. According to the control theory, there is a
relationship between pain and psychological problems like
anxiety. [8, 9] Women with lower levels of anxiety have less
pain during labour. In other words, in the presence of anxiety,
severe spasm of the pelvic floor and perineal muscles can
lead to increase in labour pain. [10]
It is also reported that prolonged labor can increase the
risk of complications to mothers, including perineal
laceration, postpartum hemorrhage, childbirth infection and
cesarean section. Also, it may cause offspring hypoxia and
complications. [11, 12]
The nursing management of labour pain is a major goal of
intrapartum care. There are many modern non-invasive
methods to relieve pain during childbirth. Among these
methods is aromatherapy. The use of aromatherapy in
nursing care continues to be popular in many settings. Most
of the nursing literature relates to the use of essential oils in
low doses for massage or use of the oils as environmental
fragrances. At the physiological level, this intervention
increases endorphins, stimulates nerves which decreases
pain, increases circulation and improves blood flow and
oxygenation of tissues. [13, 14, 15]
Aromatherapy is "the science of using highly concentrated
essential oils or essences distilled from plants in order to
utilize their therapeutic properties.” The oils may be
massaged into the skin, or inhaled by using a steam infusion.
The most common application of aromatherapy during labor
is by massage, bath or inhalation. [16, 17]
However, lavender oil is commonly used in aromatherapy.
Lavender oil is a fabulous multi-purpose essential oil.
Because of its analgesic properties it can be used to alleviate
pain in different conditions such as changing dressings,
palliative care, controlling labor pain as well as chronic pain.
The linalyl acetate component of lavender can relax smooth
muscles. [18]
Lavender essential oil also has a wonderful calming effect.
Inhaling lavender aroma diminishes the secretion of cortisol
from the adrenal gland and produces relaxation through
inhibiting sympathetic activity and stimulating the
parasympathetic system. [19] There are no studies or
published evidences that demonstrate harm from essential
oils to mother or fetus. [20]
When aroma massage is applied over the skin and enters
into the bloodstream through the skin pores, it provides a
sense of wellbeing and it reduces the need for invasive
methods of pain relief. [21] It was reported in a study that
aromatherapy helps to relieve pain, anxiety, depression,
fatigue and creates confidence and creativity. [22]
1.1. Significance of the Study
Childbirth is one of the most painful experiences and the
most significant physical challenge for women to undergo
during their lives. [23] During delivery, excessive pain leads
to fear and anxiety which will lead to increased blood levels
of hormones such as epinephrine. These will further intensify
the pain, and potentially prolong the first and second stages
of labor, thus resulting in a very unpleasant experience of
childbirth. Also, anxiety and stress during labour may
decrease the amplitude and frequency of uterine contractions
and thus, increase the labour duration and the likelihood of
assisted delivery and even Cesarean section. Moreover, more
bleeding during labor and delayed onset of lactation have
been observed among anxious women. [24] So, the use of
fragrant essential oil like lavender in massage during labour
helps to create a state of calmness, alleviate anxiety and
reduce pain. Aromatherapy massage is one of the most
popular tools that nurses can use to enhance their nursing
care and simultaneously empower themselves. [25] As a
non-pharmacological intervention, it is easy to administer,
cost effective, harmless, do not require much training, and
appealing to the mother. This intervention may be used by
nurses as a part of their routine when providing care to
women during labour. [26] So, this study provides direction
to introduce aromatherapy massage in nursing practice by
testing its efficacy on relieving labour pain and anxiety.
1.2. Aim of the Study
The aim of this study was to assess the effect of
aromatherapy massage using lavender oil on the level of pain
and anxiety during labor among primigravida women.
1.3. Research Hypotheses
1. Women who receive aromatherapy back massage with
lavender oil during active and transitional phases of
first stage of labour experience lower level of labour
pain than those who do not receive such an
intervention.
2. Women who receive aromatherapy back massage with
lavender oil during active and transitional phases of
first stage of labour experience lower anxiety level than
those who do not receive such an intervention.
2. Subjects and Method
2.1. Study Design and Setting
A randomized control clinical trial was used in this study.
The study was conducted in the labour department at El-
Shatby Maternity University Hospital in Alexandria, Egypt.
2.2. Subjects
A purposive sample of 60 pregnant women were selected
according to the following.
2.2.1. Inclusion Criteria
Primigravida.
18-35 years old, had term, singleton pregnancy.
Cephalic presentation.
Did not take analgesic drugs in the past eight hours.
Did not receive any non-pharmacological methods of
pain relief in the past eight hours.
American Journal of Nursing Science 2016; 5(2): 37-44 39
Did not have any medical and pregnancy
complications.
Normal uterine contractions.
3-4 cm cervical dilation.
2.2.2. Exclusion Criteria
Allergy to oil
After explanation and obtaining oral consent from the
women, they were randomly assigned to two groups: The
first group (n= 30) received aromatherapy back massage with
2 drops of lavender oil dissolved in 50cc almond oil and the
second group (n = 30) received massage only.
2.3. Tools of Data Collection
Four tools were developed and used to collect the
necessary data:
Tool I: An Interviewing Assessment Sheet
It was developed by the researcher and includes the
following:
Socio-demographic characteristics such as age, level of
education, occupation and residence.
History of present pregnancy and labour.
Women's satisfaction regarding massage.
Tool II: Partograph [27]:
It is a standardized design done by WHO (1994) to help in
the management of labor. This Partograph is basically a
graphic representation of the event of labor plotted against
time. Uterine contractions (intensity, duration and frequency
in 10 minutes) and maternal vital signs are also assessed.
Durations of the three stages of labor were explained as
follows (First stage: When the cervix was about 4 cm dilated
till 10 cm, second stage: From 10 cm cervical dilatation to
the delivery of baby, third stage: from the delivery of the
baby to the delivery of placenta. The fetus is also monitored
closely on the Partograph by regular observation of the fetal
heart rate and color of liquor.
Tool III. Visual analogue pain intensity scale (VAS) [28]:
The pain VAS is a unidimensional measure of pain
intensity. It is used to assess pain intensity: which represents
pain along a continuum of 2 extremes, from no pain (a score
of 0) to extreme pain (a score of 10). The pain scores were
recorded before intervention at latent phase and after
intervention at 5-7 cm and 8-10 cm cervical dilation. The
pain VAS is self-completed by the women. The women were
asked to place a line perpendicular to the VAS line at the
point that represented their pain intensity. Pain score from 1-
3 was considered mild pain, from 4-6 was considered
moderate pain and from 7-10 was considered severe pain.
Tool IV: Spielberger state-trait anxiety questionnaire [29]:
It includes 20 items of the mentioned anxiety
questionnaire. Since each item was scored as 1-4. The total
anxiety score ranged between 20 and 80: (20-40) mild
anxiety, (41-60) moderate anxiety and (61-80) severe anxiety.
This questionnaire is widely used to measure state-trait
anxiety in clinical studies and has a correlation coefficient of
0.85-0.91. [30] The anxiety levels were recorded before
intervention and after intervention at 5-7 cm and 8-10 cm
cervical dilation.
2.4. Validity and Reliability
Tool I was submitted to five academic nursing experts in
the field to test the content validity of it. Modifications were
carried out according to the academic nursing experts'
judgment on clarity of sentences and the appropriateness of
the content. Tool reliability was tested using Alpha Cronbach
test. Its result was 0.80 which indicates an accepted
reliability of the tool.
2.5. Administrative Design
Approval was obtained from the ethical committee of the
Faculty of Nursing- Alexandria.
University and the responsible authorities of the study
setting.
2.6. Pilot Study
The study tools were pre-tested on a random sample of 6
women (10%) selected from the same study setting to check
the clarity, applicability, any difficulties with their
application, and to determine the time needed for completion
of the tools. Modification of the tools was done according to
the pilot study results. Subjects who shared in the pilot study
were excluded from the study subjects.
2.7. Procedure
The study was achieved through three phases namely
assessment, implementation and evaluation.
2.7.1. Assessment Phase
The aim of this phase was to collect data about women to
determine those who have the inclusion criteria using tool I
&II. Then, they were individually interviewed by the
researcher to complete the basic data using an Interviewing
Assessment Sheet (tool I).
2.7.2. Implementation Phase
After explanation of the procedure and obtaining oral
consent of women, women were randomly assigned to
aromatherapy and control groups.
One group (n=30) received aromatherapy back massage
with 2 drops of Lavender oil dissolved in 50 cc almond
oil as a carrier oil, the second group (n=30) received
back massage only without oil.
The massage was given to all women in lateral position
by the researchers. Back massage was done gently with
medium pushing and rhythmic mode in the active phase
(cervix dilated 5-7 cm) and transitional phase (8 - 10
cm) of labour for 20 minutes every time.
2.7.3. Evaluation Phase
Then women were asked to self-rate their level of pain
before intervention at latent phase and after
intervention at active (5 -7 cm cervical dilatation) and
transitional phase (8-10 cm cervical dilatation) using
the pain visual analogue scale (tool III).
40 Sahar Mansour Lamadah and Ibtesam Nomani: The Effect of Aromatherapy Massage Using Lavender Oil on the Level of
Pain and Anxiety During Labour Among Primigravida Women
Intensity of anxiety in both groups was measured before
intervention at latent phase and after the intervention at
dilations of 5 -7 cm and 8-10 cm using the Spielberger
state-trait anxiety questionnaire (tool IV).
The women were followed during the labour process by
using Partograph (tool II).
2.8. Ethical Consideration
Before the beginning of the study, an informed oral
consent was taken from the women after explaining the aim
of the study and its phases. The participants were assured of
the confidentiality of their personal information. Women
were allowed to withdraw from the study at any time. The
data was collected over a period of 3 months from the
beginning of June to the end of August 2015.
2.9. Statistical Analysis
Data was collected, coded, tabulated and analyzed, by
using the SPSS 18.0 statistical software package. Descriptive
statistics was used to calculate percentages and frequencies,
(t) test was used to estimate the statistical significant
differences between variables. A significant P-value was
considered when it is less than 0.05 and it was considered
highly significant when P value is less than or equal 0.01.
3. Results
As shown in table (1), the age of one third of women in
aromatherapy group (33.3%) was between 25- < 30 years old
compared to 23.3% of control group. In addition, one third of
women in each group (33.3%, 33.3 %) had received
university education. More than three quarters of women in
control group (83.3%) were housewives compared to 70.0%
of women in aromatherapy group. Most of the women in
aromatherapy and control group (93.3%, 90.0%) respectively
lived in urban area.
Table (2) illustrates the mean pain scores before and after
intervention among aromatherapy and control group. The mean
pain score before intervention was (7.0) for aromatherapy group
and (8.1) for control group and there is no statistical significant
difference between them. Then after intervention, the mean pain
score decreased to (6.4) at 5-7 cm and (7.7) at 8-10 cm cervical
dilatation for aromatherapy group compared to (8.9) at 5-7 cm
and (9.6) at 8-10 cm cervical dilatation for control group. There
is a highly statistical significant difference between the two
groups (P<0.01).
As shown in table (3), the mean anxiety score was high
among the aromatherapy and control group (55.47 and 50.40)
respectively before intervention and there is no statistical
significant difference between them. However, the mean
anxiety score at cervical dilation of 5-7 cm was 38.40 in
aromatherapy group compared to 45.13 in control group. The
difference was statistically significant (P = 0.050). In
addition, the mean anxiety score was 36.63 in aromatherapy
group at 8-10 cm cervical dilatation compared to 44.07
among control group. The difference was statistically
significant (P<0.05).
As shown in table (4), the mean duration of first stage was
2.73 hours for aromatherapy group and 3.17 hours for control
group. A statistically significant difference was found (P <
0.05). During second stage of labour, the mean duration was
23.60 minutes for aromatherapy group compared to 27.23
minutes for control group and a highly statistical significant
difference was found (P < 0.01). Finally during the third
stage, the mean duration was 11.46 minutes for aromatherapy
group and 24.93 minutes for control group and a highly
statistical significant difference was found (P < 0.01).
Figure (1) reveals women's satisfaction regarding massage
during labour among the aromatherapy and control group. It
can be observed that, most of the women (82.0%) in the
aromatherapy group were satisfied compared to 69.4 % of
women in the control group. Moreover, a minority of women
from aromatherapy and control group (3.7 %, 10.0%)
respectively were dissatisfied.
As shown in figure (2), all the aromatherapy group (100%)
had normal vaginal delivery compared to 96.4% from control
group.
Table 1. Distribution of the study subjects according to their socio-demographic characteristics (n = 60).
Items Aromatherapy group Control group
n = 30
% n=30 %
Delete this empty raw
Age
< 20 2 6.7 8 26.7
20 - < 25
10 33.3 6 20.0
25- < 30
10 33.3 7 23.3
30 - 35 8 26.7 9 30.0
Educational level
Read and write 5 16.7 4 13.3
Primary
5 16.7 7 23.3
Secondary
10 33.3 9 30.0
University 10 33.3 10 33.3
Occupation:
House wife 21 70.0 25 83.3
Work
9 30.0 5 16.7
American Journal of Nursing Science 2016; 5(2): 37-44 41
Items Aromatherapy group Control group
n = 30
% n=30 %
Delete this empty raw
Residence
Urban 28 93.3 27 90.0
Rural
2 6.7 3 10.0
Total
30 100.0 30 100.0
Table 2. Mean pain scores before and after intervention among aromatherapy and control group.
Dilatation stage Aromatherapy group Control group t p
Mean SD Mean SD
Before intervention (Latent phase) 7.0 .11
8.1 .14 4.9 0.08
5-7 cm dilatation (Active phase) 6.4 .20
8.9 .19 16.5 0.002
8-10 cm dilatation (Transitional phase) 7.7 .17 9.6 .50 20.1 0.000
Table 3. Mean anxiety scores before and after intervention among aromatherapy and control group.
Dilatation stage Aromatherapy group Control group t P
Mean SD Mean SD
Before intervention (Latent phase) 55.47 9.91 50.40 5.75 3.04
0.07
5-7 cm dilatation (Active phase) 38.40 6.53 45.13 9.10 8.04 0.05
8-10 cm dilatation (Transitional phase) 36.63 8.05 44.07 9.95 14.9 0.03
Table 4. Mean duration of labor stages among aromatherapy and control group.
Labour stage Aromatherapy group Control group t p
Mean SD Mean SD
Duration of first stage (Hours) 2.73
1.05 3.17 1.23 12.6
0.04
Duration of second stage (Minutes) 23.60
15.35 27.23
2.21 17.9
0.006
Duration of third stage (Minutes) 11.46 2.31 24.93 8.37 7.8
1
0.005
Figure (1). Women's satisfaction regarding massage during labour among aromatherapy and control group. (please put it under the figure directly)
42 Sahar Mansour Lamadah and Ibtesam Nomani: The Effect of Aromatherapy Massage Using Lavender Oil on the Level of
Pain and Anxiety During Labour Among Primigravida Women
Figure (2). Types of delivery among aromatherapy and control group.
4. Discussion
When a woman faces the childbirth process for the first
time, she often feels anxiety because coping with labour pain
is usually viewed as an anxious moment. Labour pain is
considered the most unpleasant aspect of labour experience.
Labour pain is progressive, with rapid alterations of its
location and an increase in severity with advancing dilatation
and intensity of uterine contractions. [31, 32] Aromatherapy
is one of the non-pharmacological methods for pain relief
and Lavender oil is a mild sedative and antispasmodic. Also,
the essential oil derived from lavender is used in
aromatherapy to treat anxiety. [33] The study achieved its
hypotheses in demonstrating that lavender aromatherapy
massage is effective in relieving labour pain and anxiety.
The results of the current study showed a reduction in the
mean pain score among the aromatherapy group compared to
the control group and the difference is statistically significant.
This means the effectiveness of lavender oil in labour pain
reduction which may be due to the sedating effects of linalool
acetate in lavender as a narcotic. [34] These results are in line
with the results of Janula R and Mahipal S (2015) who
reported the effectiveness of aromatherapy massage in
reducing labor pain during all labour stages. [21] Also, the
results of Zahra A and Leila M (2012) revealed that lavender
oil massage was effective method in decreasing pain during
labor at cervical dilatation of 4-5cm, 6-7cm and 8-10 cm. [33]
In addition, Chang et al (2002) had a study in which
aromatherapy massage is effective intervention for labor pain
reduction. [35] Burns et al. (2000) also confirmed that
aromatherapy is useful way to relieve pain and strengthen the
uterine contractions during labor. [34]
A randomized control trial was done in India to assess the
effect of aromatherapy massage on labour pain intensity,
there were no maternal adverse effects and the study
achieved its main objective that, lavender aromatherapy
massage was effective in relieving labour pain and its
intensity and reducing duration of labour in experimental
group whereas in massage only group, there was not a
reduction in pain intensity and duration of labour. [26]
However, the results of the current study are contradicted
with the results of a systematic review by Smith et al. (2011)
on 535 women in comparing aromatherapy with placebo for
pain management of labor, there was no difference between
groups for the pain intensity and the length of labor. The
authors, however, concluded that further research is needed
before final recommendations. [36]
The mean anxiety scores among the two groups in the
present study showed that Lavender aromatherapy massage
could reduce anxiety during labor.
These results are
congruent with the results of Namazi M et al (2014) who
found that the levels of anxiety at dilatations of 3-4 and 6-8
cm were significantly lower in the aromatherapy group
compared with the control group
.
[37] Also, Hee rho et al.
(2009) who investigated the effects of aromatherapy massage
on the anxiety and self-esteem experienced by elderly
Korean women found that, there was a significant difference
in the anxiety and self-esteem among the two groups. [38]
Imanishi J et al. (2009) reported that anxiety scores
significantly decreased after each aromatherapy massage
session. [39] According to Smith et al (2011) and Bastard et
al (2006), essential oils improved mood and reduced anxiety
during labor by stimulating the olfactory pathways in the
limbic system. [36, 40]
Moreover, the results of current study are in accordance
with the results of a study carried out by Osaka et al (2009)
about the administration of a hand massage. Despite the short
duration of only five minutes, a statistically significant
reduction of the perception of anxiety could be achieved
from massage only. [41] Furthermore, Bastered et al (2009)
had a study which confirmed that aromatherapy massage
have successfully been used to produce significantly greater
improvement in reduction of anxiety during labour. [42]
Also, Susan Mousley et al (2005) had a study in which
aromatherapy massage is aiding relaxation and reducing
anxiety during labour. [43] Similarly Jennings and Wilkinson
(2004) reported that lavender oil promotes relaxation, and it
may give soothing effect to the skin and stimulate the nerve
endings when applied like a massage. [15]
Prolonged duration of first stage of labour is an important
cause of Caesarean and instrumental vaginal delivery. If
duration of labour is prolonged, it may cause offspring
hypoxia. [26] The results of the present study reveal that the
mean length of labour duration also reduced in the first,
second and third stages of labour among aromatherapy group
compared to control group and the difference was
statistically significant. These results are congruent with the
results of Raju and Signh (2014) who found significant
difference between aromatherapy and biofeedback group
regarding labour duration. [26]
Aromatherapy is an effective, non-pharmacological pain
relief method. The present study showed that most of the
women in the aromatherapy group were satisfied with the
aroma massage. These results are in line with results of Raju
and Signh (2014) and Chang et al (2002) who mentioned that
the majority of women reported satisfaction about their
labour experience. [26, 35]
American Journal of Nursing Science 2016; 5(2): 37-44 43
5. Conclusion and Recommendations
5.1. Conclusion
From the results of the current study, it can be concluded
that aromatherapy massage with lavender oil can reduce
labour pain and anxiety during labour. Also, it is an effective
way to decrease labor duration. Most of the women were
satisfied by this intervention. This method can influence the
quality of care provided during childbirth by reducing the
suffering of women in labour.
5.2. Recommendations
Based on the findings of the present study, the following
recommendations are suggested:
1. Aromatherapy massage using lavender oil can be
offered to women in labour who want to avoid
pharmacological methods for pain relief.
2. Further studies are required to investigate the effects of
aromatherapy massage on neonatal outcomes.
3. A comparative study can also be done between the
effectiveness of various non-pharmacological measures
for labour pain.
4. Provide an educational program for nurses about
aromatherapy.
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